Online faculty development in low- and middle-income countries for health professions educators: a rapid realist review

Faculty development is an inherently complex concept due to the nature of the interventions and the recipient context's variability, approach to delivery and purpose. Many literature, narrative and scoping reviews related to faculty development report positive programme outcomes [1] without expanding on the mechanism's complexity and operational standing to achieve these [1‐4]. One of these reviews specifically called for further research into online faculty development to determine what works, for whom and in what circumstances [3]. This call reinforces the longstanding need to investigate the complexities inherent in online faculty development, catalysed in 2020/2021 by face-to-face facilitation restrictions during the COVID-19 pandemic.

Faculty development has evolved rapidly over the last 30 years by adapting to changes in the environment, educational theory and technology [5]. Globally, the literature reports that faculty development opportunities are usually institution-specific, in-person programmes or workshops for non-degree purposes, or delivered as part of a postgraduate qualification [1, 4, 6, 7]. Faculty development practitioners generally claim these faculty development opportunities positively impact health professions educators [1, 4, 8] who require support to develop their teaching and learning, research, educational leadership, and administration skills. These skills are part of the health professions educators' practice. Their development strengthens their role in higher education, especially in low- and middle-income countries, where professional development opportunities are scarce [6].

The current situation within low and middle income countries limits opportunities for professional development of health professions educators in practice. At a national scale, there is limited funding for human resource development, where other competing national priorities such a healthcare service delivery take precedence [9]. Health professions educators who happen to have opportunities for professional development are normally engaged in specific clinical skills development and not necessarily focused on approaches to teaching and learning, research and educational leadership. Arguably, due to limited resources within the low- and middle-income countries—there is limited numbers of professionals with expertise to develop health professions educators. This situation creates an opportunistic approach towards faculty development of health professions educators in the low- and middle-income countries through institution-based piece-meal programmes that may not be transferrable. These programmes may not be underpinned by educational theory limiting approaches to scientifically evaluate their influence within low- and middle-income countries. Theoretically sound online faculty development has the potential to positively impact the practice of health professions educators. Educational design literature describes frameworks and guidelines grounded in theory for designing and delivering online teaching and learning [10] that creates an opportunity for deep and meaningful collaborative learning. Three of these frameworks are Community of Inquiry, Conversational framework and Community of Practice. The Community of Inquiry, as an example, has three transactional factors that intersect to enhance the effectiveness of learning in blended and online learning environments. Two of these factors, namely, cognitive presence, where learners construct meaning through sustained reflection and discourse, and teacher presence, where the teacher or facilitator meaningfully facilitates course design with collaborative intent, relate directly to the learning environment design [11]. Furthermore, the Conversational Framework [10] provides educators with a theoretical approach to teaching and learning in a technology-driven society by framing the approach to teaching as an interactive dialogue. Utilising multiple learning theories, the Conversational Framework presents learning and teaching as an iterative process of generating and modulating concepts between the teacher, learner and the environment [10]. A realist review [12] found the Conversational Framework to be prevalent in internet-based medical education. In a Community of Practice (CoP), group participatory learning takes place and technology offers more people to learn together through the use of online communities [13]. In this paper, the authors argue that a Community of Practice (CoP) underpinned by the Conversational Framework and Community of Inquiry is crucial for the positive outcomes of an online faculty development course for health professions educators in low- and middle-income countries.

First developed as a concept linked to social learning, CoPs consist of three dimensions; a joint enterprise, mutual engagement and a shared repertoire of communal resources focused on organisational learning [14]. Two decades after Wenger's seminal work on COPs was published, Li and colleagues proposed a set of characteristics for CoPs within the health professions sector [15]. These characteristics are a context that supports formal and informal interaction, fosters a sense of belonging, and emphases learning and sharing knowledge [15]. Conversely, these characteristics align with the theoretical assertions of understanding online learning through a Community of Inquiry lens [11]. The social, cognitive and teaching presence described in the Community of Inquiry [11] aligns with the interaction between peers and between facilitators/peers, social learning and knowledge sharing. However, the evidence for improved practice through CoPs has been limited to initiatives with explicit efforts aimed at developing communities in face-to-face or blended community environments [4, 16, 17] middle- and high-income settings.

This paper presents a synthesis of literature with an explanatory focus aimed to unpack the mechanisms of how online faculty development work (or why they fail) in low- and middle-income countries by establishing causal relationships necessary to understand underlying mechanisms and the context in which those relationships occur.

The objective of this review was to establish the context, mechanism, and outcome (CMO) of online health professions education faculty development in low- and middle-income countries. The review question was: How do online health professions education faculty development programmes work, or not work, in low- and middle-income countries?

This rapid realist review used a Conjecture Map developed with the Conversational Framework and Community of Inquiry as the theoretical basis for online health professions education faculty development courses' design considerations. The findings of the review partially supported selecting these candidate theories, specifically the Community of Inquiry, as underpinning asynchronous online learning. The programme theory was not reliant on the technical or design considerations of online faculty development for health professions educators, which would have supported the Conversational Framework as a core theory influencing course design. The Conversational Framework provides the parameters from which to assess the role of using feedback from the learning environment, the student and between students to adapt the design of the learning environment [10]. Further confirmation of the appropriate candidate theories emanated from three articles that reported a theoretical framework for evaluating their faculty development opportunity [27, 29, 31], two of which incorporated the Community of Inquiry into the design and evaluation of their faculty development opportunity [27, 31]. The third article applied the Kirkpatrick evaluation model to their study [29]. This outcome, paired with the CMO analysis, implies that the mechanism through which faculty development outcomes in low- and middle-income countries are achieved may be due to creating a community of educators, thus answering the “Why online faculty development courses in low- and middle-income countries work?”.

The existence or development of a community of educators facilitates collaborative learning within higher education [11]. In the context of faculty development, this review demonstrates the validity of interrogating the effectiveness of designing interventions through the lens of a community of practice [4]. This community should be focused on capacity development through collaborative learning and practice [29]. Furthermore, research has shown that faculty development should adopt an approach in which a community of practice is a critical outcome [34] in face-to-face and online initiatives [3].

Similar to earlier research identifying a positive correlation between cognitive presence and community [35], this review found that the positive developmental outcomes within well-designed, purpose-driven online courses consistently relied on the domains and categories that align with the Community of Inquiry and a Community of Practice. When an online course creates a mental discomfort secondary to contradictory information also known as "cognitive dissonance", the Community of Inquiry posits that cognitive dissonance is a stimuli or a triggering event for cognitive development [8]. In the process of theory building within this review, the authors found that the "triggering event" aligned with the Cognitive Presence in the Community of Inquiry is not specifically the existence of a sense of puzzlement or being lost in meaning [36], but rather the creation or existence of a Community of Practice. Aligning the themes—the Conjecture Map, the CMO configurations and the Community of Inquiry—highlights the recurrence of the teacher and cognitive presence constructs in these interventions.

This review identified six triggering events as critical in developing a community of practice in an online faculty development course for health professions educators in low- and middle-income countries. These are programme type, programme design, discussion, engagement, development, and collaboration. These events align with the Conjecture Map, predominantly within the embodiment of the course, outlining the salient design principles that include the tools, activities, materials, participant structures and discursive practices. Each of these either creates a "common ground for sharing knowledge", "a social structure for interactions", or creates and curates "specific knowledge shared, developed and maintained by the community [4]." Utilising the Community of Practice as a lens through which to analyse the design and theoretical conjectures for online health professions education courses is supported through the intended application of this theory [37] (Table 3).

The authors answered the "what works, in what context, and why it works" within this review. In the light of these, the authors interrogated the data to identify "for whom" these initiatives work effectively. Considering the original intention of this review and efforts to ensure an approach to design and delivery of non-institutional online health professions education faculty development opportunities specifically for the low- and middle-income country context, there is a question of whether the foreign gaze [38] evident within the data is necessary for achieving the presented outcomes.

Literature and reviews have raised the notion of the foreign gaze in the context of Global Health [38]. Similarly, in the field of faculty development for health professions educators, the focus is primarily on developed countries [6], written by and for, that is, the pose and gaze in relation to international audiences [38]. The question that the finding of this review raises is whether this can be attributed to publications that are more likely to emanate from a foreign gaze perspective, assuming what works in low- and middle-income countries. The reviewed articles were primarily US-based in origin, ownership of the intervention or authorship profile, thus written with a foreign pose and with a foreign gaze to international audiences. While the authors concede that the triggering event of programme type could be an internationally funded and resourced intervention, the question is whether the foreign gaze is a necessary catalyst for developing the resultant online community in a low- and middle-income context. Faculty development initiatives in Africa have incorporated communities of practice as a capacity development opportunity [39]. However, in the study presenting this finding, US funding was relied on in a "partnership", calling into question cultural alignment with the recipients' needs at the inception of the programme [2]. The answer to the question relating to "for whom?” online health professions education faculty development courses work indicates educators and clinical educators as the recipients. This review cannot unequivocally state that this is true for facilitators from low- and middle-income countries, as the facilitators in all studies were a combination of both local and foreign.

As an outcome of this rapid realist review, the programme theory generated is that "health professions educators in low- and middle-income countries (context) can develop professional and inter-personal skills (outcome) through a well-designed, specifically constructed online community that prioritises active discussion (mechanism)".

This rapid realist review aimed to answer how online health professions education faculty development courses work or do not work in low- and middle-income countries. The approach to executing this review highlights the possibilities of integrating educational design research tools for the development of candidate theories and the realist review approach. This review's findings demonstrate the community's role as the dominant mechanism through which these interventions work, based on a design that incorporates six triggering events. The study aligns these events with the three categories of the Community of Inquiry, a theory applicable to the design of online learning environments. Health professions educators in low- and middle-income countries can develop professional and interpersonal skills through a theory-based purposeful online community that prioritises active discussion. Finally, this rapid realist review highlights deficiencies in the quantity publications and the influence of a foreign gaze on the evidence available within this field. As part of a larger research project, this study supports our final recommendation that further research is required to contextualise these findings through a consultative process to develop a model for designing and delivering online health professions education faculty development courses within a low- and middle-income setting.

Relevant data and materials have been provided as Additional Files 1 and 2, referenced in the manuscript.